29954 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 29954
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MKCIIANICAL
BUILDING PROJRCI'FiRmnFICATION
BUILDINGADDRSANITARY NO. APPLICATION SUBMITTAL DATE
qIi 5: S�iq 6
OWNER'S AMR: PHOS- #TRACTOR:S NAME LIC NO:
�B-SI NIC CONTROL#
CHITL. d E LIC NO: A D ..S: ❑
COM'ALT/e,I• I i a� PHONE: BUILDING PERMIT INFO
M ElConsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
S ❑ ❑ ❑
L CENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 herehy affirm that I not Ecensed nnaer provi:ion..at Chapter 9(camtnendng JOB DESCRIPTION
Owith Secdnn 70601 of Division]oFlhc I{usiness and Rofessinns Cale,send my license is
PERMIT ISSUANCE. RESIDENTIAL:
in to=and effort. ❑SFDWI. ❑KITCHEN REMODEL
�Zac Licenser Cla Lie.# APPLIANCES-RESIDENTIAL
fn<6 Date Cnnemnor ❑ADDITION ❑PLUMBING RE-PIPE
R-Cvs ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
Z O „Z-, 1 understand my plans shall he used as public records MODIFICATION
CZ O s - - UP TO 200 AMPS [3 INTERIOR ❑CHIMNEYRF,PAIR
Licensed professional
OWNER-BUILDER DECLARATION PS 20L10(XIAMIMPROVIDENT
r�yF
y❑y Y E hereby amffirshat I am exempt from the Contractors License Law for the OVEREOEAPS
❑BATH REMODEUREPAIR �❑DEMOLI
s(34 F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER W' 1 ,�` %
LLLL17=4C which requires n permit to construct,alter,improve,demolish,or repair any structure " As
pnorloinis.......1,orcgmms We.pplimm forauchpmm,mfilessignedst.mmem SI'ECIALCIRCUIT/MISC.
(hat he is Each l pursuant to the provisions ollhe Contractor's License Law(ChnpmT,9
COQ (commencing wird Sminn 7fl(MI)of Division 3af she easiness and ProfessionsCMe)or THMR.METER OR POLE INST. COMMERCIAL:
IL yy c 4• that he is exempt thertfmm and me basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
p(�N Beckon 7113 L5 by any epplkam(ora permit suM1jems she upplicanuou civil penalty of POWER BE VICES El TENANT ❑FOOD SERVICE
not more than five hundred do[].(S500) IMPROVEMENT
6� ❑hunwnera(Ihe property,or my employees with wages as their sole compcvetian. SWIMMING POOL ELECTRIC
will do the work,and the structure,is not intended oroffered for sale(Sec.7610,Business ❑UTHER
and Professions Code:The Connector's License Law does not apply to an owner of OUTLETS-SWITCHES-17MURES tt a
a' property who builds or improves Merton,and who does such work himself or enough
his own employees,provided that such improvements arenot intended of offered for NEW RESIDENTIAL ELEC R S
salo.IL@twee<g the building urimprovement is eMAwithin ane yaandcomplelion,tbe SJWALEfTrr00�AREA SISQ,FT.
owner-huilderveill have We burden nfproving that he did one build or improve for put. VI/ y ly1.596
poseafwleJ.
❑ I.as owner of the property,am esclasively contracting with licensed contractors to TOTAL: vs`'
construct me project(Sec.7194,Business and Professions Code:)The C....mntors Li- I I I/('
ase Law does not apply man owner of property who builds or improves thereon.and QTY PLUMBING PERMIT HE
- WWI-Li,fllt(J
who ommocts far vetch pr.jecD with a m.tawmr(s)licensed pursuant m me Commcntrs
License Law, PERMITISSUANCE
1 sm exempt under Sm. ,B M P C for this mason
Owner Data ALTER-DRAINAt VENT-WATER(VA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
t r (herehy affirm under penalty of perjury one of the following diaration: ,
I have and will maintain a Certificate of Consent to self-insum for Workers Compen- DRAINS-MODEL ROOF,AREA,COND. STORIES TYPBCONSTRUCION
,.Burt,us provided for by Section 371M1 of the Lubar Calc,for We performance of the
work for which this permit is issued. FIXTURIS-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Code,for the perlhrmance of the work for which this permit is issued, GAS-EA.SYSTEM-1 INC.40UTLETS OCC.GROUP APN
My Worker's Compensation I......a earriettud Policy number are: GAS Cartier. Policy No.: EA.SYSTEM-OVER 4(Eli
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPGNSAUON I NSURANCE GREASEIINDUSTR 1,WASTE INTERCEPTOR
pbicsecsion need not be completed ifthe permit is forime hundred dollar.(51001 BUILDING UIV ISION hEIi.S
or lose.) permitGREASE TRAP PLANCHECK FEE
Ioymy Wrl in the anymarmaeof the become
for whichthis tpernal he Workers Cancer.
(shall
oat employ my person in eery manner so ns to become suhjecno the Warkert Compen- SGWGN-SANITARY-STORM P.A.2(N)Nr. ENEµGY FEH '
Z ..tion laws of Culifnerm.Data
0 O Applicant WATER HEATER WNENTRiLECTR GRADING FR
q NOTICE'I'O APPLICANT.If,after making this Ceailicum of Exemption,you should WATER SYSTEW)HEATING
Ise^ become subject m the Worker.Compensation Provisions of the labor Cade,you most SOILS FEE
{t1 forthwith comply with such provisions ser this permit.hull be deemed revoked. WATER SERVICE
Q
UO CONSTRUCTION LGNDINGAG1gNCY NEW RFSIDEN'1'IAI.PCMB, SQ,FT. PAID
I herebyaffimt Immat i is.col Sm.3"97,
agency for performanceof Use ipep
w !-t she work for which this permit is lssuul(Su.3R97,Cie CJ
0 U Lender's Name OTAL:
DJ lenders Address TOTAL:
I certify that I have read this application and state that above information is FEE
UL42 comet.l agree to comply with all city and county ordinances and stale laws relating In QTY. MECHANICAL PERMIT AHCOUSINOMITICATI
Z building convection,and hembyauthorife reprcsenestims ofthis city to enter upon the E'
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to neve,indemnify and keep harmless the City of Cupertino against 1
liabilities,judgments,casts and expenses whichmzy in any way accree mumu s.at City ALTER OR ADD TO MECH. FEE
m consequence of the granting.(this petmir
APPLICANT UNDERSTANDS AND WILL WITH ALL NON•POINT AIR HANDLING UNIT CEO 10,000 CFM)
SOURCE.REGULATE NS. AL FEE
AIR HANDLING USE'r(OVER to,"CFM( TIONTAX
S*911 mn App0 a"' Oor - D EXHAUST HOOD(WMUCT MITIGATE H
AZARDOUS MATERIALS DI. SURE
Will theapplens orfuture building occupant s rhundle haasrdma ma¢rial HEATING UNIT CEO InfIXMI BTU)
a,defined by the Cupedinn Municipal Code.Chapter 9.12,and at,Health and Safcry
Code,Section 25532001 HEATING UNIT(OVER IW,O( BTU)
loss ❑No VENTILATION PAN(SINGLE RESID) PAID
Dunt ReciptN
Will the oit comet ser future building by the B use .A it u or devices which BOILER-COMP(311P OR 100,000 BTU
mit ice? m air etmuminents as defined by the Bay Areo Air Quality M.nagement ) TOTAL:
D
istrict?
�fcs ❑No BOILFRR-COMP(OVER IW,(N PTU
I have read the lu'.a materials rtquiremcnn under Chaptorfi95 of the Cali AIR CONDITIONER ISSUANCE DATE
ria limith&Safety Cade,Sections 255059 25533 and 2,5534.1 understand net If she NEW RESIDENTIAL SUCH SQ,IT.
hoveatenenL ghee it is my respmsibilitymneify the uccupam gnu'w It use rte 'nen 1s neeufaCenificmemOccupancy of .gem Dam TOTAL: ISSUED BY:
OFFICE,